fahad bamehriz, md ass.prof collage of medicine, king saud university consultant advanced...
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FAHAD BAMEHRIZ, MD
Ass.Prof Collage of Medicine, King Saud University
Consultant Advanced Laparoscopic and Robotic surgery
Benign Gastric and Duodenal diseases
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ObjectivesDefinitionPresentationDiagnosistreatment
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PEPTIC ULCEREsophagusDuodenumStomachJejunum after surgical construction of
agastrojejunostomyIleum in relation to ectopic gastric mucosa
in Meckles diverticulum
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IntroductionMen are affected three times as often as
women Duodenal ulcers are ten times more
common than gastric ulcers in young patients
In the older age groups the frequency is about equal
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Presentation- Pain- Bleeding- Perforation- Obstruction
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DUODENAL ULCEREpigastric area, mid-day, noon,nightRelieved by foodNormal or increased acid secrtionCommon in young – middle age male95% in duodenal bulb (2cm)90% principle cause is H pylori (GNCB
aeroph)
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DiagnosisEpigastric area pain and tendernessEGDGastric analysis ( basal vs maximal)Gastrin serum level (severe or refractory )Contrast meal (show complication)
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TREATMENTMedical Treatment (80% in 6 weeks) -H2 antagonsis (zantac……) - Proton pump inhibetors (omperazol…..) - H.pylori eradication (amoxicillin ,
clarithro..) Surgical Treatment I. VagotomyII.Antrectomy and vagotomyIII.Subtotal gastrectomy
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Complications of surgery for peptic ulcer Early Complications (leakage, bleeding,
retension)Late Complications1.Recurrent ulcer (marginal ulcer, stomal
ulcer ,anastomotic ulcer)2.Gastrojejunocolic and gastrocolic fistula3.Dumping syndrome4.Alkaline gastritis5.Anemia (Iron defi and vitB12 …) 6.Postvagotomy diarrhea7.Chronic gastroparesis
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ZOLLINGER-ELLISON SYNDROME (Gastrinoma)Peptic ulcer disease (often severe) in 95%Gastric hypersecretion Elevated serum gastrin Single one is malignantMultiple is benign (MEN 1)GASTRIN LEVEL IS MORE THAN 500 pg/ml C T Scan, somatostatin scanPortal vein blood sample
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Treatment Medical Treatment Surgical Treatment
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GASTRIC ULCER Epigastric area painIncrease by foodCommon in 40-60 years male95% along lesser curve Types : - Type 1 : in incisura angularis & normal
acid -Type 2: prepyloric and DU & high acid - Type 3: antrum duo to NSAID - Type 4: at GEJ
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DiagnosisEpigastric tenderenessEGDContrast swallow
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TreatmentMedical TreatmentSurgical Treatment: distal hemi gastrectomy & ulcer excision
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UPPER GASTROINTESTINAL HEMORRHAGEHematemesisMelenahematochezia
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Causes of massive upper gastrointestinal hemorrhage
Relative Incidence
Common causes peptic ulcer Duodenal ulcer Gastric ulcer Esophageal varices Gastritis Mallory-Weiss syndrome
Uncommon causes Gastric carcinoma Esophagitis Pancreatitis Hemobilia Duodenal diverticulum
25%20%
45%
20%20%10%5%
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MALLORY-WEISS SYNDROME10% of UGIB1-4cm longitudinal tear in gastric mucosa
at EGJForceful vomitingEGD90% bleeding stops spontaneously by cold
gastric wash, EGD- cautery, surgery
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PYLORIC OBSTRUCTION DUE TO PEPTIC ULCERMedical TreatmentSurgical Treatment
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PERFORATED PEPTIC ULCERLocate anteriorlyHigh risk : female, old age, gastric oneAcute presentationX-ray: free air (85%) & fill 400 cc air by NGTTreatment : NGT, ABS, Surgery
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STRESS GASTRODUODENITIS, STRESS ULCER & ACUTE HEMORRHAGIC GASTRITISStress Ulcer -----shock &sepsisCurling’s ulcers----burnsCushing’s Ulcer ----CNS tumor, injury (more
to perforates, high acid productionAcute Hemorrhagic Gastritis
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GASTRIC POLYPS Types : - Hyper plastic - Adenomatous - inflammatoryAffecting distal stomachPresentation by anemiaEGDR/O malignancy
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GASTRIC LEIOMYOMAS Common submucosal growthAsymptomatic & massive bleedingEGD & C T ScanDo not biopsySurgical wide excision
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MENETRIER’S DISEASEGiant hypertrophy of the gastric rugaePresent with hypoproteinemiaEdema, diarrhea, weight lossTreatment : atropine, omperazole, H,pylori
eradication …..rarely is gastrectomy
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PROLAPSE OF THE GASTRIC MUCOSAOccasionally accompanies small gastric
ulcerVomiting and abdominal painX-ray : antral folds into duodenumAntrectomy with Billroth 1
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GASTRIC VOLVULUS Its longitudinal axis( organo-axial volvulus): - More common - Associated with HHLine drawn from the mid lesser to the mid
greater curvature( mesenterioaxial volvulus )
Present with :Severe abdominal pain and Brochardt”s
triad
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Brochardt’s triad1. Vomiting followed by retching and then
inability to vomit 2. Epigastric distention 3. Inability to pass a nasogastric tube
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GASTRIC DIVERTICULAUncommonAsymptomaticWeight loss, diarrheaEGD, X-ray?? surgery
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BEZOARConcretions formed in the stomach Types: - Trichobezoars: hair - Phytobezoars: vegtabPresentation by obstructionEGD, X-RAYSURGICAL REMOVAL
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DUODENAL DIVERTICULA20% OF POPULATIONAsymptomatic90% medial aspect of the duodenum Rare before 40 years of ageMost are solitary and 2.5 cm peri-
ampullary of vater
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Benign Duodenal TumorsBrunner’s gland adenomasCarcinoid tumorsHeterotopic gastric mucosaVillous adenomas
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SUPERIOR MESENTERIC ARTERY OBSTRUTION OF THE DUODENUMObstruction of the third portion of the
duodenum --compression SMA and AortaAppears after rapid weight loss following
injuryDistance between two vessels is 10-20 mm
Proximal bowel obstruction symptoms and signs
C T Scanbypass
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REGIONAL ENTERITIS OF THE STOMACH & DUODENUMFood poisingPain and diarrheaClinical DXobservation